NCLEX® Medical Surgical Nursing Practice Exam

Preparing for the NCLEX isn’t about memorizing endless facts—it’s about thinking like a safe, confident nurse under pressure. This NCLEX® Medical Surgical Nursing Practice Exam is designed to help you do exactly that. Built around the real structure and clinical focus of the NCLEX, it trains you to apply knowledge, prioritize care, and make the right decisions when it matters most.

Medical-Surgical Nursing is the backbone of the NCLEX, forming a major part of the exam’s Physiological Integrity category, where you’re tested on real patient care scenarios across multiple body systems . That means you’re not just recalling information—you’re analyzing symptoms, choosing interventions, and identifying risks in dynamic clinical situations. This practice exam mirrors that experience with realistic, exam-style questions that reflect how the NCLEX actually tests you.

Inside, you’ll work through a wide range of high-yield topics, including cardiovascular, respiratory, endocrine, renal, and neurological conditions—along with pharmacology, patient safety, and clinical decision-making . Each question is paired with a clear, practical explanation that helps you understand not just what the correct answer is, but why it’s correct—so you can build strong clinical judgment, not just surface-level knowledge.

This isn’t just another question set. It’s a focused tool to sharpen your critical thinking, improve prioritization skills, and get comfortable with NCLEX-style wording and logic. Whether you’re struggling with complex disease processes or second-guessing your answers, this practice exam helps you identify weak areas and turn them into strengths.

If your goal is to pass the NCLEX with confidence—and think like a nurse, not just a test-taker—this Medical Surgical practice exam gives you the depth, realism, and clarity you need to get there.

What is Medical-Surgical Nursing?

Medical-surgical nursing is the backbone of adult inpatient care. It blends sharp clinical assessment with calm, decisive action to manage complex, multi-system problems across the lifespan. A med-surg nurse might start the shift titrating oxygen for a COPD exacerbation, pivot to recognizing evolving stroke symptoms, and finish by educating a family about heart-failure self-management. The role demands competency in cardiology, pulmonary care, neuro, renal and endocrine balance, gastrointestinal and liver disorders, infectious disease, peri-op, wound and skin integrity, heme-oncology, and emergency response. You’re prioritizing, delegating, preventing complications, and teaching—often all at once.

Beyond task skill, medical-surgical nursing hinges on pattern recognition and prevention: catching sepsis before shock, reading a telemetry trend that whispers “hyperkalemia,” or stopping a transfusion when the first red flag appears. It’s also about systems thinking—bundles for ventilator-associated pneumonia, fall reduction, pressure-injury prevention, and safe medication administration. Whether you practice on a bustling med-surg floor, float to step-down, or support procedural units, mastery here is the foundation for every specialty. That’s why the medical surgical nursing exam is so valued by hospitals and certification boards—and why realistic, targeted preparation matters.

About This Exam

This NCLEX® Medical-Surgical Nursing Practice Test was built from authentic bedside scenarios and decision points that mirror the way questions are written on national boards. Each item follows a clean stem → answer → detailed rationale format so you learn the why, not just the what. You’ll tackle high-yield situations med-surg nurses see constantly—flash pulmonary edema, DKA vs HHS, post-tPA precautions, status asthmaticus rescue meds, acute cholangitis bundles, and hypertensive emergencies—alongside nuanced calls like recognizing autonomic dysreflexia triggers, separating ileus from mechanical obstruction, and choosing first-line vasopressors.

Expect mixed formats, including SATA (Select All That Apply) to strengthen clinical patterning. Every rationale emphasizes safety, priority setting (ABCs/Maslow), pathophysiology cues you can spot in seconds, and the nursing actions that change outcomes: when to hold potassium before insulin, how to titrate oxygen in COPD to 88–92%, how to position for increased ICP, and what belongs in the sepsis first-hour bundle. If you’re searching for medical surgical nursing certification practice questions, medical surgical nursing exam questions, or a reliable medical surgical nursing test bank, this exam gives you focused reps that translate directly to the bedside—and to the test screen.

Our Cover Topics:

Cardiovascular: STEMI/ASA at first contact, right-ventricular infarct management, aortic dissection beta-blocker-first strategy, HFrEF guideline pillars (ARNI/ACEI/ARB, evidence-based beta-blockers, MRA, SGLT2), pericarditis distinguishing features, pericardial tamponade recognition and response, hypertensive emergencies with safe MAP reduction, and aortic stenosis syncope. These are classic medical surgical nursing board exam questions topics.

Respiratory & Critical Care: Status asthmaticus escalation with IV magnesium, COPD exacerbation O₂ targets and NIV, tension pneumothorax decompression site, ARDS lung-protective ventilation (6 mL/kg IBW, PEEP, plateau ≤30), inhalation injury early intubation, and VAP prevention bundles.

Endocrine/Metabolic: DKA sequence (fluids → K⁺ ≥3.3 → insulin), HHS hallmarks (hyperosmolar, minimal ketones), euglycemic DKA with SGLT2 inhibitors, thyroid storm medication order (β-blocker → thionamide → iodine → steroids), myxedema coma ABCs, Addisonian crisis resuscitation, pheochromocytoma pre-op blockade order—core medical surgical exam practice tests content.

Renal & Electrolytes: Hyperkalemia stabilization with IV calcium, contrast-associated AKI prevention, rhabdomyolysis high-rate fluids and electrolyte strategy, hemodialysis catheter infection control, dialysis disequilibrium, SIADH safe correction targets, and DI after neurosurgery pattern recognition.

Neurology: Ischemic stroke workflows (glucose first, permissive hypertension vs tPA thresholds), post-tPA bleed avoidance, dysphagia screening before oral intake, meningitis droplet isolation + antibiotics timing, Cushing triad for herniation, Guillain-Barré bedside spirometry (VC/NIF) to anticipate intubation.

GI/Hepatology: Upper GI bleed sequencing with airway first, variceal bundle (octreotide + antibiotics + urgent banding), pancreatitis nutrition (early enteral, low-fat), diverticulitis outpatient vs inpatient, acute cholangitis resuscitation + ERCP, hepatic encephalopathy with lactulose targets, ascites diuretic ratios and sodium restriction.

Heme/Onc & Sepsis: Massive transfusion balanced ratios (≈1:1:1), transfusion reaction first steps, neutropenic fever antibiotics within 60 minutes, tumor lysis prophylaxis (hydration + allopurinol/rasburicase), and the sepsis first-hour bundle essentials.

Infection Control & Safety: C. difficile soap-and-water plus sporicidal cleaning, contact vs droplet vs airborne, pressure-injury prevention and DTPI recognition, chest-tube troubleshooting (air leaks, tidaling), PCA no-proxy rule, and fall-risk/wound care pearls.

Across these systems, you’ll see the same judgment patterns the medical surgical nursing exam rewards: rapid triage, escalation pathways, and precise sequence of interventions. It’s the opposite of trivia—every item teaches a mental model you’ll reuse.

Who Should Take This Exam?

• NCLEX® candidates who want a rigorous, med-surg-heavy warm-up with realistic rationales.
• New-to-practice nurses building confidence on core adult-care pages and protocols.
• Med-Surg RNs preparing for certification who need medical surgical nursing certification practice questions that feel like the real thing.
• Float pool, ED, and step-down nurses who want fast-twitch decision practice for high-acuity scenarios.
• Educators and preceptors looking for reliable medical surgical nursing test bank material to anchor review sessions.

Why our Med Surg Nursing Practice Questions useful?

• Exam-style alignment: Wording, distractors, and SATA design are tuned to how national questions are written, not just content recall.
• High-yield selection: Cardiac, respiratory, endocrine, renal, neuro, emergencies, and infection control dominate real test blueprints—this set leans into them.
• Actionable rationales: Each explanation connects assessment findings to first-line interventions so you can cut through noise on exam day and at the bedside.
• Coverage breadth: From autonomic dysreflexia to cholangitis to post-op hematoma airway threats, this is a full-spectrum medical surgical nursing exam workout.

Study Tips: How to Pass Medical Surgical Exam?

1. Train the sequence, not just the fact. For DKA, say it out loud: Fluids → check K⁺ → insulin → close gap → basal overlap. For thyroid storm: β-blocker → thionamide → iodine → steroids. On exam day, the right order earns points and saves lives.
2. Anchor “first actions” to safety frameworks. ABCs, neuro monitoring, and sepsis bundles are always fair game. If the stem screams airway risk (hematemesis with confusion, post-thyroidectomy neck swelling, inhalation injury), your first move should reflect that priority.
3. Practice SATA with a checklist mindset. Read each option as a true/false statement. Pick only what’s independently correct. Our SATA items mirror the way med-surg content appears in medical surgical nursing board exam questions.
4. Use “look-for” phrases to speed recognition.
   • Right-sided MI clue: clear lungs + hypotension + JVD after nitrates → fluids, no nitrates, V4R.
   • HHS vs DKA: severe dehydration/neurologic deficits + minimal ketones → fluids first, slow osmolality correction.
   • AD (T6+): pounding headache + severe HTN → sit up, fix bladder/bowel trigger.
   • Tamponade: hypotension + JVD + muffled tones → urgent decompression.
5. Space your practice. Do 10–20 questions daily, not 100 once a week. After each block, skim only the rationales you missed and one or two you got right for reinforcement. This keeps your recall fresh and avoids burnout.
6. Pair questions with micro-review. Miss a COPD oxygen target? Spend 5 minutes reviewing gas exchange and V/Q mismatch. Miss ARDS ventilation? Write a sticky note: 6 mL/kg IBW, PEEP, plateau ≤30; consider proning. These mini-reviews build durable memory.
7. Simulate test conditions. Quiet room, strict timing, no notes. Confidence under exam pressure comes from realistic rehearsal with medical surgical nursing practice questions that look and feel like the real thing.
8. Teach it back. Explain a tricky topic to a peer in 60 seconds: “Why is calcium the first drug in life-threatening hyperkalemia?” If you can teach it simply, you own it.
9. Mind your metrics. Track weak areas by system and theme (e.g., electrolytes, isolation, anticoagulation). Focus your next sessions on those, drawing from this medical surgical nursing test bank to convert weaknesses into wins.
10. Rest and routine. The week before testing, keep a steady sleep schedule, short daily drills, and one day fully off. Cognitive performance peaks with rest, not cramming.

Medical Surgical Nursing Sample Questions and Answers

1) Priority: Post-op abdominal surgery (Day 1)

A client 24 hours post-colectomy reports increasing abdominal pain, HR 112, T 38.3°C (100.9°F), abdomen distended and firm, no flatus. Which action is the priority?

A. Administer PRN opioid
B. Notify HCP of suspected ileus or obstruction
C. Encourage ambulation and warm fluids
D. Apply heat to abdomen
Correct: B
Explanation: In the first 24–48 hours after abdominal surgery, paralytic ileus or early obstruction should be suspected with distention, absent flatus, increasing pain, and low-grade fever. Priority follows ABCs + acute changes and risks that threaten perfusion and integrity. While ambulation (C) and fluids may help motility, the combination of distention, tachycardia, fever, and firmness suggests a complication that may require imaging, NGT decompression, or changes to orders. Opioids (A) could mask assessment and worsen constipation, and heat (D) might increase vasodilation without addressing the cause. Immediate provider notification enables timely diagnostics and prevents bowel compromise or perforation.

2) Cardiac: Heart failure education

Which statement by a client with chronic HF indicates effective teaching?

A. “I’ll weigh myself once a week.”
B. “I’ll limit sodium to ~2 g/day.”
C. “If my ankles swell, I’ll rest and recheck next week.”
D. “I can skip diuretics if I feel tired.”
Correct: B
Explanation: Evidence-based HF self-management includes daily weights, low-sodium diet (~2 g/day), medication adherence, and early reporting of edema or >2–3 lb weight gain in 24 hr or 5 lb in a week. Thus B shows accurate diet control. A is insufficient—daily weights are recommended for early fluid detection. C delays care; new/worsening edema requires prompt contact. D risks fluid overload and hospitalization; diuretics should be taken as prescribed. Education also covers fluid limits per HCP, monitoring for dyspnea/orthopnea, and reading food labels for hidden sodium.

3) Respiratory: COPD exacerbation

A client with COPD is dyspneic with RR 28, using accessory muscles, SpO₂ 88% on 2 L/min via NC. Which initial intervention is best?

A. Increase O₂ to 4 L/min per protocol
B. Encourage fluids to thin secretions
C. Administer PRN antitussive
D. Position in high-Fowler’s and coach pursed-lip breathing
Correct: D
Explanation: For acute dyspnea, non-invasive measures that improve ventilation come first: high-Fowler’s to maximize chest expansion and pursed-lip breathing to reduce air trapping and prolong exhalation, improving oxygenation and CO₂ elimination. Oxygen may be titrated (A) but should follow facility protocol and be reassessed; excessive O₂ can blunt hypoxic drive in some COPD clients, though modern practice prioritizes maintaining SpO₂ 88–92%—titrate after positioning and breathing techniques. Fluids (B) are supportive but not immediate relief. Antitussives (C) may impair secretion clearance during exacerbations.

4) Endocrine: DKA vs HHS

Which finding most specifically supports DKA rather than HHS?

A. Serum glucose 560 mg/dL
B. pH 7.28 with positive serum ketones
C. Serum osmolality 320 mOsm/kg
D. Altered mental status
Correct: B
Explanation: DKA is characterized by hyperglycemia, metabolic acidosis (low pH/bicarbonate), ketonemia/ketonuria, and anion-gap acidosis—more common in type 1 diabetes. HHS shows more profound hyperglycemia/osmolality and dehydration but minimal or no ketosis and near-normal pH. Glucose >500 (A) occurs in both. Osmolality 320 (C) is more typical of HHS but can overlap. AMS (D) can occur in both but is classic/severe in HHS due to hyperosmolarity. Therefore, pH 7.28 plus ketones is the most distinguishing DKA indicator, guiding urgent fluid resuscitation, insulin infusion, and electrolyte management.

5) Neuro: Stroke (ischemic) tPA eligibility

A client arrives 1.5 hours after onset of unilateral weakness and aphasia. BP 168/94, CT shows no bleed. Which action is priority?
A. Start aspirin 325 mg
B. Screen for recent surgery and bleeding risks for tPA
C. Lower BP to 120/80 before thrombolysis
D. Start heparin infusion
Correct: B
Explanation: Within the 3–4.5-hour window for tPA (alteplase) in ischemic stroke, rapid contraindication screening is critical: recent surgery, anticoagulant use, bleeding disorders, severe uncontrolled hypertension, or prior intracranial hemorrhage. BP can be permissively elevated initially; aggressive lowering (C) is not first. Aspirin (A) is used when tPA is not given or afterward per protocol, not before tPA. Heparin (D) is not indicated acutely and increases bleeding risk. Prompt screening enables timely reperfusion, maximizes neurologic recovery, and minimizes hemorrhagic conversion.

6) GI: Upper GI bleed
The client with melena and dizziness has BP 92/58, HR 118, cool clammy skin. Which order should the nurse implement first?

A. Type and crossmatch
B. Start large-bore IV and infuse isotonic fluids
C. Administer IV proton pump inhibitor
D. Prepare for EGD in morning
Correct: B
Explanation: Signs of hypovolemic shock (hypotension, tachycardia, cool clammy skin) require immediate volume resuscitation with isotonic fluids via large-bore IV. Restoring perfusion prevents organ ischemia. Type and crossmatch (A) are crucial but follow IV access and stabilization. PPI (C) reduces acid and supports hemostasis but is secondary to hemodynamic stabilization. Scheduling EGD (D) is important for diagnosis/treatment but only after initial resuscitation and stabilization per ACLS/bleeding protocols. Continuous monitoring for mental status, urine output, and serial H/H is essential.

7) Renal: Acute kidney injury (pre-renal)

Which finding supports pre-renal AKI from dehydration?

A. Urine sodium >40 mEq/L
B. Fractional excretion of sodium (FENa) <1%
C. Urine osmolality <300 mOsm/kg
D. Red cell casts in urine
Correct: B
Explanation: Pre-renal AKI features intact tubules conserving sodium and water; FENa <1% indicates avid sodium reabsorption. Urine osmolality is typically high (>500) due to concentration; low osmolality (C) suggests tubular dysfunction. Urine sodium >40 (A) and granular/cellular casts (D) are more consistent with intrinsic AKI (e.g., ATN or glomerulonephritis). Early identification of pre-renal causes (hypovolemia, decreased perfusion) guides prompt fluid resuscitation, avoidance of nephrotoxins, and hemodynamic optimization to prevent progression to intrinsic damage.

8) Heme/Onc: Neutropenic precautions

A chemotherapy client’s ANC is 400/µL. Which instruction is most important?

A. “Avoid fresh flowers and standing water.”
B. “Use an electric shaver.”
C. “Report temperature ≥38.0°C (100.4°F) immediately.”
D. “Limit visitors to family only.”
Correct: C
Explanation: Severe neutropenia (ANC <500) places clients at high risk for sepsis; fever is an emergency requiring immediate evaluation and empiric IV antibiotics. While reducing environmental pathogens (A), minimizing injury (B), and limiting exposure (D) are appropriate, the most time-sensitive action is prompt fever reporting. Education includes meticulous hand hygiene, avoiding raw/undercooked foods, daily temperature checks, and recognizing subtle infection signs (sore throat, cough, dysuria) because inflammatory responses may be blunted in neutropenic clients.

9) Musculoskeletal: Hip fracture pre-op

Which positioning is best for an elderly client with a suspected hip fracture awaiting x-ray?

A. Trendelenburg with legs extended
B. Affected leg adducted and internally rotated
C. Supine with slight abduction and external rotation supported
D. Prone with pillows under hips
Correct: C
Explanation: Suspected hip fracture often presents with external rotation and shortening. Maintaining a neutral, slightly abducted position with support minimizes pain and prevents displacement. Internal rotation/adduction (B) can worsen alignment and pain. Trendelenburg (A) is inappropriate and uncomfortable. Prone (D) is unsafe and difficult to monitor. Pre-op care focuses on pain control, neurovascular checks, fall precautions, and preventing pressure injuries while expediting imaging and surgical planning.

10) Fluid/Electrolytes: Hyperkalemia on telemetry

A client with CKD has K⁺ 6.2 mEq/L and peaked T waves. Which order is priority?

A. Administer calcium gluconate IV
B. Start sodium polystyrene sulfonate
C. Begin loop diuretic
D. Provide low-potassium diet education
Correct: A
Explanation: Hyperkalemia with ECG changes threatens lethal dysrhythmias. IV calcium gluconate stabilizes the myocardial membrane immediately, buying time for potassium shift/removal strategies (insulin + dextrose, β-agonists, bicarbonate if acidotic, dialysis). Kayexalate (B) works slowly; diuretics (C) only help if kidneys can excrete. Diet education (D) is preventive, not emergent. Continuous cardiac monitoring and repeat labs are required. Evaluate for precipitating causes (ACEi/ARBs, spironolactone, tissue breakdown) and prepare for dialysis if refractory or with severe renal failure.

11) Acid–Base: ABG interpretation

ABG: pH 7.31, PaCO₂ 50 mmHg, HCO₃⁻ 24 mEq/L. What is the imbalance?

A. Metabolic acidosis
B. Respiratory acidosis uncompensated
C. Respiratory alkalosis
D. Metabolic alkalosis partially compensated
Correct: B
Explanation: Low pH indicates acidosis. Elevated PaCO₂ with normal HCO₃⁻ indicates primary respiratory acidosis with little/no metabolic compensation (uncompensated). Causes include COPD exacerbation, hypoventilation (opioids), airway obstruction, or severe pneumonia. Management targets improving ventilation: airway positioning, bronchodilators, pulmonary hygiene, cautious oxygen titration in COPD, and addressing sedative effects. Serial ABGs monitor response. Distinguishing from metabolic causes is essential to guide therapy.

12) Infectious disease: Contact precautions

Which condition requires contact precautions?

A. Influenza
B. C. difficile colitis
C. Tuberculosis
D. Measles (rubeola)
Correct: B
Explanation: C. difficile spreads via spores that resist alcohol; contact precautions and soap-and-water hand hygiene are essential. Dedicated equipment and environmental cleaning with sporicidal agents reduce transmission. Influenza is droplet; TB is airborne with N95; measles is airborne as well. Nurses must don appropriate PPE, perform hand hygiene rigorously, and ensure antimicrobial stewardship (avoid unnecessary antibiotics) to prevent CDI occurrences and recurrences, especially in older adults and those on PPIs or chemotherapy.

13) Post-op: PCA opioid safety

Which instruction is most important for a client starting a PCA morphine?

A. “Family can press the button if I’m asleep.”
B. “I will press the button when I begin to feel pain.”
C. “I should press repeatedly to get more than the set dose.”
D. “I should avoid pressing before coughing or ambulation.”
Correct: B
Explanation: Patient-controlled analgesia must be activated only by the client, preventing oversedation/respiratory depression that can occur with family activation. Pressing at pain onset prevents severe pain peaks and supports pulmonary hygiene and mobility. The lockout interval prevents overdosing, so repeated pressing (C) is ineffective and unnecessary. Pre-emptive dosing before coughing/ambulation is appropriate (contrary to D). Monitor sedation scores, respiratory rate, and oxygenation; have naloxone available per policy.

14) GI/Liver: Cirrhosis and ascites

Which diet instruction is best for a cirrhosis client with ascites?

A. High sodium to maintain blood pressure
B. Low sodium and adequate protein as prescribed
C. Fluid restriction avoided to prevent dehydration
D. No protein to prevent encephalopathy
Correct: B
Explanation: In cirrhosis with ascites, sodium restriction reduces fluid retention; adequate protein supports healing and albumin synthesis unless contraindicated (severe encephalopathy may require temporary adjustments). High sodium (A) worsens ascites. Fluid restriction (C) may be ordered if severe hyponatremia but is not universally avoided. Completely eliminating protein (D) is outdated and leads to malnutrition. Additional management includes diuretics (spironolactone ± furosemide), daily weights, paracentesis for refractory ascites, and alcohol abstinence.

15) Endocrine/Thyroid: Thyroid storm

Which assessment finding is most concerning for thyroid storm?

A. Bradycardia and fatigue
B. Hyperthermia, tachycardia, agitation
C. Weight gain and cold intolerance
D. Dry skin and constipation
Correct: B
Explanation: Thyroid storm is a life-threatening hyperthyroid crisis with high fever, tachycardia/arrhythmias, agitation/delirium, GI symptoms, and potential heart failure. Immediate management includes antithyroid drugs, iodine (after thionamides), beta-blockers for sympathetic symptoms, steroids for adrenal support, cooling measures, and treating triggers (infection, surgery, trauma). Bradycardia, cold intolerance, dry skin, and constipation (A/C/D) are hypothyroid features. Prompt recognition and rapid supportive care reduce mortality.

16) Renal: Hemodialysis access care

Which action is appropriate for a client with an AV fistula?

A. Measure BP on the fistula arm
B. Draw labs from the fistula
C. Palpate for thrill and auscultate for bruit each shift
D. Apply tight bandage over the site
Correct: C
Explanation: AV fistula patency assessment includes checking for a palpable thrill and audible bruit every shift. No BP, IVs, or blood draws on the access arm to prevent thrombosis and vessel damage. Avoid constrictive clothing or dressings (D). Educate clients to avoid sleeping on the arm, report bleeding, and perform hand-grip exercises per protocol post-creation. Pre-/post-dialysis assessments include weight, edema, lung sounds, and monitoring for hypotension or cramping.

17) Oncology: Extravasation of vesicant

During doxorubicin infusion, the client reports burning at the IV site; redness and swelling are noted. First action?

A. Slow the rate
B. Stop the infusion and notify HCP
C. Apply warm compress
D. Flush the IV line
Correct: B
Explanation: Vesicant extravasation demands immediate cessation of infusion while leaving the catheter in place for potential antidote administration, then notify the provider and follow protocol (e.g., antidotes, cold vs warm compress depending on drug). Flushing (D) can spread the vesicant and worsen tissue injury. Slowing rate (A) is unsafe. Compress choice (C) varies by agent—some require cold to limit spread; others use warmth to disperse—so follow drug-specific guidelines. Early intervention prevents necrosis and functional loss.

18) Peri-op: Informed consent

Which client can sign surgical consent?

A. A sedated client who received midazolam 10 minutes ago
B. A 17-year-old emancipated minor
C. A client with severe dementia without a legal representative
D. A client who speaks only Spanish with no interpreter
Correct: B
Explanation: An emancipated minor generally can consent per state law. Sedation (A) impairs capacity; informed consent must be obtained before sedatives. Clients lacking capacity (C) require a legally authorized representative. Language barriers (D) require a qualified interpreter to ensure understanding. Nurses witness consent and clarify information but do not obtain it; the provider explains risks/benefits/alternatives. Document teaching, questions, and the client’s understanding.

19) Endocrine/DM: Insulin mixing

Which combination can be safely drawn up in one syringe?

A. Glargine with lispro
B. NPH with regular insulin
C. Detemir with aspart
D. Glargine with NPH
Correct: B
Explanation: NPH (intermediate) can be mixed with regular insulin (short-acting). Draw clear (regular) before cloudy (NPH) to avoid contamination. Basal analogs (glargine, detemir) must not be mixed with other insulins due to pH/formulation differences affecting absorption and action. Educate about onset/peak/duration, hypoglycemia signs, site rotation, and carbohydrate intake. Verify orders and perform double-checks per insulin safety policy to prevent medication errors.

20) Neuro: Increased ICP care

Which intervention helps lower intracranial pressure?

A. Hyperflex the neck to improve venous return
B. Keep head midline and HOB 30 degrees
C. Suction frequently for 20 seconds each pass
D. Provide hypotonic fluids
Correct: B
Explanation: Head midline with HOB 30° facilitates cerebral venous drainage and reduces ICP. Neck hyperflexion (A) obstructs jugular outflow and raises ICP. Suctioning (C) increases ICP; if needed, pre-oxygenate and keep passes short (<10 seconds). Hypotonic fluids (D) worsen cerebral edema; isotonic fluids are preferred. Avoid Valsalva (stool softeners), maintain normothermia, and monitor neuro status. CO₂ management (brief hyperventilation in acute herniation) is a temporary measure under provider direction.

21) Cardiac: Warfarin education

Which statement shows correct understanding?

A. “I’ll keep my vitamin K intake consistent.”
B. “Cranberry juice won’t affect my INR.”
C. “I’ll take ibuprofen for headaches.”
D. “I don’t need INR checks once stable.”
Correct: A
Explanation: Consistent vitamin K intake avoids INR swings on warfarin. Cranberry and grapefruit can interact and affect INR; clients should consult HCP (B incorrect). NSAIDs increase bleeding risk; acetaminophen is usually safer within limits (C incorrect). Regular INR monitoring remains necessary, even when stable, due to diet, drug interactions, and illness (D incorrect). Educate on bleeding signs, safety with razors/soft toothbrush, and notifying providers before procedures or new medications.

22) Respiratory: Pneumonia outcomes

Which finding indicates improvement after antibiotic therapy for community-acquired pneumonia?

A. WBC from 16,000 to 18,500/µL
B. SpO₂ from 88% on 4 L to 93% on 2 L
C. Temp from 37.2°C to 38.5°C
D. RR from 20 to 26/min
Correct: B
Explanation: Improved oxygenation with lower O₂ requirement indicates clinical recovery. Rising WBC (A), fever increase (C), and tachypnea (D) suggest worsening inflammation or inadequate response. Additional indicators of improvement include decreased purulent sputum, improved breath sounds, resolving infiltrates over time, and clinical stability (HR, BP). Reinforce deep breathing, incentive spirometry, hydration, and early ambulation to enhance ventilation and secretion clearance.

23) GI/Pancreatitis: Acute management

Which order is most consistent with acute pancreatitis care?

A. High-fat diet as tolerated
B. NPO with aggressive IV fluids and pain control
C. Immediate broad-spectrum antibiotics
D. Early enteral feeding via PO
Correct: B
Explanation: Acute pancreatitis requires NPO to rest the pancreas, aggressive isotonic fluids for third spacing, and pain control (often opioids). Nutrition typically advances to enteral via nasojejunal tube if prolonged NPO is expected; early PO (D) can worsen pain and enzyme secretion. Antibiotics (C) are not routine unless infected necrosis is suspected. Monitor for complications: hypocalcemia, hyperglycemia, respiratory failure (ARDS), and sepsis. Evaluate etiology (gallstones, alcohol, hypertriglyceridemia).

24) Shock/Sepsis: Early recognition

A post-op client becomes confused, with HR 124, BP 86/52, T 38.6°C, RR 24, lactate 4.2 mmol/L. Best initial action?

A. Give antipyretics and reassess
B. 30 mL/kg isotonic fluid bolus and blood cultures
C. Start vasopressors immediately
D. Restrict fluids due to hypotension
Correct: B
Explanation: This presentation is consistent with septic shock: hypotension, tachycardia, fever, AMS, elevated lactate. Early goal-directed therapy includes broad-spectrum antibiotics after blood cultures and rapid fluid resuscitation (30 mL/kg) to restore perfusion. Vasopressors (C) follow if MAP <65 despite fluids. Antipyretics (A) are supportive but not definitive. Fluid restriction (D) is contraindicated. Continuous monitoring, source control, and serial lactates guide response.

25) Endocrine/Adrenal: Addisonian crisis

Which finding is expected in acute adrenal crisis?

A. Hypertension and hypernatremia
B. Hypotension, hyponatremia, hyperkalemia
C. Bradycardia and hypokalemia
D. Respiratory alkalosis only
Correct: B
Explanation: Adrenal crisis involves cortisol/aldosterone deficiency → hypotension, hyponatremia, hyperkalemia, dehydration, and shock risk. Immediate treatment includes IV hydrocortisone, isotonic fluids with dextrose for hypoglycemia, and electrolyte correction. Hypertension/hypernatremia (A) are opposite. Bradycardia/hypokalemia (C) are inconsistent. Acid–base disturbances vary; metabolic acidosis may occur (D not definitive). Identify triggers (infection, abrupt steroid withdrawal) and provide stress-dose steroids for illness or surgery.

26) Delegation SATA: RN vs UAP

Which tasks can the RN delegate to an experienced UAP? Select all that apply.

A. Ambulate a stable post-op day-2 client with gait belt
B. Obtain routine vital signs on a stable client
C. Teach incentive spirometry to a new post-op client
D. Feed a client at risk for aspiration after stroke
E. Report urine output less than 30 mL/hr
Correct: A, B, E
Explanation: UAPs can perform non-invasive, routine tasks: ambulation of stable clients (A) with precautions, obtaining vital signs (B), and observing/reporting outputs (E). Teaching (C) is an RN responsibility; UAP may reinforce after RN teaches/evaluates. Feeding a client at aspiration risk post-stroke (D) requires RN assessment and often SLP clearance; initial feeding is not delegated. Use the right task, circumstance, person, direction, and supervision (5 rights of delegation).

27) Blood transfusion reaction

During PRBC transfusion, the client develops fever, chills, and back pain. First action?

A. Slow the transfusion and reassess
B. Stop the transfusion and keep IV line open with normal saline
C. Administer acetaminophen and continue
D. Send the blood bag to pharmacy
Correct: B
Explanation: Suspected acute hemolytic reaction → stop transfusion immediately, maintain IV access with normal saline, and notify provider/blood bank. Monitor vitals, urine output, and collect labs (hemolysis markers, direct Coombs). Slowing (A) is unsafe. Antipyretics alone (C) are inadequate. The bag/tubing (D) must go to the blood bank, not pharmacy, for evaluation. Strict identification checks before transfusion prevent ABO incompatibility, the most serious reaction.

28) Ortho: Total hip arthroplasty precautions

Which instruction is correct after posterior hip replacement?

A. Cross legs to prevent stiffness
B. Keep knees together when sitting
C. Use abduction pillow to prevent dislocation
D. Bend forward to tie shoes at 2 weeks
Correct: C
Explanation: After posterior THA, avoid hip flexion >90°, adduction, and internal rotation. An abduction pillow helps maintain alignment and prevents dislocation, especially when turning. Crossing legs (A) and keeping knees tightly together (B) increase adduction risk. Bending to tie shoes (D) risks excessive flexion; use adaptive devices. Emphasize fall prevention, elevated seats, and signs of dislocation (sudden pain, limb shortening, internal rotation). Follow PT guidelines for progressive mobility.

29) GI: Ostomy care

Which finding requires immediate HCP notification for a new ileostomy?

A. Stoma pink and moist
B. Small amount of serosanguinous drainage
C. Stoma dark, dusky, or black
D. Gas passing into pouch
Correct: C
Explanation: A dusky/black stoma suggests ischemia/necrosis, a surgical emergency. Normal findings include a pink to red, moist stoma with mild edema and small serosanguinous drainage in early post-op. Gas (D) indicates bowel function returning. Report absent output with increasing pain/distention, or high-volume watery output causing dehydration/electrolyte imbalance. Skin care, proper pouch fit, and hydration are key teaching points, especially for ileostomies with liquid output.

30) Priority SATA: Post-thyroidectomy hypocalcemia

A client 12 hours post-thyroidectomy reports tingling around the mouth and fingers; Chvostek sign is positive. Which actions should the nurse take now? Select all that apply.

A. Prepare to administer IV calcium gluconate
B. Apply oxygen and place on cardiac monitor
C. Encourage deep breathing and fluids
D. Notify the HCP
E. Reassure and reassess in 2 hours
Correct: A, B, D
Explanation: Post-thyroidectomy hypocalcemia from parathyroid injury causes tetany, paresthesias, and laryngospasm risk. IV calcium is the treatment of choice for symptomatic hypocalcemia; apply oxygen and place on telemetry due to arrhythmia risk. Notify the HCP promptly for orders and evaluation. Reassurance/waiting (E) is unsafe; respiratory compromise can occur rapidly. While hydration (C) is benign, it does not address the acute electrolyte emergency. Frequent neuro-muscular checks and airway readiness are essential.